twenty-four
10:22 A.M., Sunday, March 24, 2002
If, over the years, going to a physician had become emotionally difficult for Ashley Butler because of its unwanted reminder of his mortality, going into a hospital was worse, and his arrival at the Wingate Clinic had been no exception. As much as he joked about his generic alias with Carol in the limo en route and used his Southern charm on the nurses and technicians during admission, he was terrified. The thin veneer of his apparent insouciance was particularly challenged when he met the neurosurgeon, Dr. Rashid Nawaz. He was not as Ashley had pictured, despite having been told his plainly ethnic name. Prejudice had always played a role in Ashley’s thinking, and it was operative now. In his mind, brain surgeons were supposed to be tall, serious, and commanding figures, preferably of Nordic heritage. Instead, he was confronted by a short, slight, dark-skinned individual with even darker lips and eyes. On the positive side was a lilting English accent that reflected his Oxford training. Also on the positive side was an aura of confidence and professionalism leavened with compassion. The man recognized and sympathized with Ashley’s plight as a patient facing an unorthodox treatment and was gently reassuring, telling Ashley the upcoming procedure was not at all difficult.
Dr. Carl Newhouse, the anesthesiologist, was more in keeping with Ashley’s expectations. As a mildly overweight Englishman with ruddy cheeks, he looked like the Caucasian doctors Ashley had encountered in the past. He was dressed in OR scrubs complete with a hat and a facemask. The facemask was tied around his neck but dangled over his chest. A stethoscope was draped around his neck, and a collection of pens protruded from his breast pocket. A tourniquet of brown rubber tubing was coiled around his pants’ tie.
With exhaustive thoroughness, Dr. Newhouse had gone over Ashley’s medical history, particularly in relation to allergies, drug reactions, and episodes of anesthesia. While Dr. Newhouse auscultated and thumped Ashley’s chest as part of a cursory physical examination, he also started an IV with such practiced ease that Ashley hardly felt it. Once it was flowing to Dr. Newhouse’s satisfaction, he told Ashley that he’d be giving him a powerful intravenous cocktail that would make him feel calm, content, possibly euphoric, and definitely drowsy.
“The sooner the better,” Ashley had silently voiced. He was more than ready to feel calm. With his fears about the upcoming procedure, he’d had difficulty falling asleep the night before. And on top of the psychological stress, it had not been an easy morning. Following Daniel’s advice, he’d avoided his Parkinson’s medication, with consequences more severe than he’d anticipated. He hadn’t appreciated the extent to which the drugs had been controlling his symptoms. He’d not been able to stop his fingers from an involuntary rhythmical motion as if he were trying to roll objects in his palms. Worse yet was the stiffness, which he likened to trying to move while totally immersed in gelatin. Carol had to get a wheelchair to get him down to the waiting limo, and two doormen had to struggle to get him from the wheelchair into the car. The arrival at the Wingate had been equally difficult, with equivalent indignity. The only good part of the ordeal was that no one seemed to have recognized him, thanks to his tourist disguise.
Dr. Newhouse’s intravenous cocktail had been everything he’d promised and then some. Currently, Ashley felt considerably more content and calm than if he’d downed several tall tumblers of his favorite bourbon, and this was in spite of being seated in a tiled operating room on an operating table cranked up to a sitting position with both arms splayed out to the sides and secured to armboards. Even his tremor was better, or if it wasn’t, at least he wasn’t aware of it. He was clothed in a skimpy hospital johnny with his stocky, pasty white legs thrust out in front of him. His bare, dry, and bunioned feet with curling yellow toenails pointed up at the ceiling. The IV was in one arm and a blood-pressure cuff around the other. EKG leads were attached to his chest, and the beeping of the readout echoed about the room.
Dr. Nawaz was busy with a tape measure, a marking pen, and a razor, as he prepared Ashley’s head for the stereotaxic frame, which Ashley could see next to a collection of sterile instruments on a draped table off to the side. Despite the frame appearing like a torture device, Ashley, in his drugged state, was unconcerned. Nor was he bothered about Dr. Lowell and Dr. D’Agostino, who had appeared with Dr. Spencer Wingate and Dr. Paul Saunders at a window looking out into the operating suite hallway. Dressed in scrubs, the foursome seemed to be watching the preparations as if it were entertainment. Ashley would have liked to wave, but he couldn’t with his hands tied. Besides, it was hard to keep his eyes open, much less lift his arms.
“I’ll be shaving and prepping small areas on the sides and back of your head,” Dr. Nawaz announced, while handing the marking pen and tape measure to Marjorie Hickam, the circulating nurse. “These will be the sites where the frame will be secured to your head, as I explained earlier. Do you understand, Mr. Smith?”
It took a moment for Ashley to remember his assumed name was Mr. Smith and that he was being addressed. “I believe I do,” he announced in a slurred monotone. “Perhaps you could shave my face while you’re at it. Without my medication, I’m afraid I did less than a commendable job this morning.”
Dr. Nawaz laughed at this unexpected humor, as did the other occupants in the room, which included a scrub nurse by the name of Constance Bartolo. She was already gowned and gloved, and stood next to the table with the frame and the instruments as if on guard.
A few minutes later, Dr. Nawaz stepped back and eyed his handiwork. “I’d say that looks rather good. I’ll duck out to scrub, then we’ll drape, and we can begin.”
Despite what should have been a terrifying circumstance of waiting to have a hole drilled into his skull, Ashley fell into a peaceful, dreamless slumber. He was soon partially awakened by the sensation of sterile drapes settling over him, but he rapidly fell back asleep. What succeeded in waking him a few minutes later was a sudden, searing scalp pain on the right side of his head. With great effort, he partially pulled up his heavy eyelids. He even tried to lift his right arm against its restraint.
“Easy!” Dr. Newhouse said. He was standing behind and to the side of Ashley. “Everything is okay!” He laid a restraining hand on Ashley’s arm.
“I’m just injecting some local anesthesia,” Dr. Nawaz explained. “You might feel a stinging sensation. There are going to be four locations.”
“Stinging sensation!” Ashley marveled silently in his stupor. It was just like a doctor to downplay the symptom, because the pain was more like a white-hot knife cutting his scalp away from his skull. Yet Ashley was strangely detached, as if the pain involved someone else and he was a mere observer. It also helped that in each instance, the pain was fleeting, to be replaced by absolute numbness in the area.
Ashley was only vaguely aware of the process of being fitted with the stereotaxic frame. He floated effortlessly in and out of consciousness during the more than half hour of manipulations and adjustments it took to anchor the frame with pins attached firmly to the outer table of his skull. He had no awareness of the past, the future, or the passage of time.
“That should do it,” Dr. Nawaz said. He reached up and grasped the calibrated semicircular arms that arched over Ashley’s head and gently tested the frame’s stability by trying to move it in any direction. It held solidly, with its four setscrews rooted into the senator’s cranium. Pleased with the result, Dr. Nawaz stepped back, clasped his sterile, gloved hands against his gowned chest, and cleared his throat. “Miss Hickman, if you would be so kind, please let X ray know we are ready for them.”
The circulating nurse stopped in her tracks en route to getting another bottle of IV fluid for Dr. Newhouse. Her gray-blue eyes first looked at her colleague Constance for a modicum of support before meeting Dr. Nawaz’s gaze. For the moment, Marjorie was at a loss for words, since she’d had experience during her training with neurosurgeons’ short fuses and operating-room tantrums, and she expected the worst.
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“I say,” Dr. Nawaz announced with an edge to his voice, “let’s not dally. It is time for the X ray.”
“But we don’t have any X ray,” Marjorie said hesitantly. She switched her attention to Dr. Newhouse for corroboration, lest she bear the full brunt of responsibility for the current problem.
“What do you mean there’s no X ray?” Dr. Nawaz demanded. “You bloody well better have an X ray, or we’ll be wrapping up and going home! There’s no way I can do an intracranial implantation without an X ray.”
“What Majorie means is that these two operating rooms were not set up for X ray,” Dr. Newhouse explained. “They were designed primarily for infertility procedures, so they have state-of-the-art ultrasound available. Would that be of assistance?”
“Absolutely not!” Dr. Nawaz snapped. “Ultrasound would be no help whatsoever. I need a full size X ray to get accurate measurements. The frame’s three-dimensional reference grid has to be related to the patient’s brain. Otherwise, it would be like shooting in the dark. I need some bloody X rays! You mean to tell me you don’t even have a portable machine?”
“Unfortunately, no!” Dr. Newhouse said. He waved through the window for Paul Saunders to come into the room.
Paul poked his head through the door while holding a mask to his face. “Is there a problem?”
“You’d better believe there’s a bloody problem,” Dr. Nawaz complained angrily. “I’ve been informed belatedly that there is no X ray.”
“We have X ray,” Paul said. “We even have MRI.”
“Well, get the blasted X ray in here!” Dr. Nawaz commanded impatiently.
Paul stepped into the room and looked back out at the others through the window. He waved for them to come in, which they did, holding masks to their faces like he was.
“There is a problem no one thought of,” Paul said. “Rashid needs X ray, but the room is not set up for it, and we have no portable unit.”
“Oh, for Christ’s sake! After all this effort, is it going to come down to this?” Daniel asked rhetorically. Then, looking directly at the neurosurgeon, he said, “Why didn’t you mention you needed an X ray?”
“Why didn’t you tell me it wasn’t available?” Dr. Nawaz retorted. “I’ve never had the dubious honor of working in a modern OR that didn’t have access to X ray.”
“Let’s think about this a moment and let cooler minds prevail!” Paul suggested. “There has to be a solution here.”
“There’s nothing to think about,” Dr. Nawaz snapped. “I cannot localize an injection into the brain without X rays. It is as simple as that.”
Except for the metronomic beeping of the cardiac monitor, the room sank into a strained silence. Everyone avoided locking eyes with anyone else. No one moved.
“Why not take the patient to the X-ray room,” Spencer suggested suddenly. “It’s not that far.”
The others had thought of the idea but dismissed it. Now they reconsidered the suggestion. Taking a patient from the OR to the X-ray room in the middle of a procedure was hardly routine, yet it wasn’t out of the question in the current circumstance. The facility was brand-new and practically empty, so contamination was less of an issue than it would have been normally, especially since the craniotomy had not yet been made.
“I have to say it sounds reasonable to me,” Daniel said optimistically. “We’ve got enough hands. We can all help.”
“What’s your opinion, Rashid?” Paul asked.
Dr. Nawaz shrugged. “I suppose it would work, provided we keep the patient on the OR table. With him sitting up and the stereotaxic frame in place, it would be ill-advised to move him on and off a gurney.”
“The OR table is on wheels,” Dr. Newhouse reminded everyone.
“Let’s do it!” Paul said. “Marjorie, alert our imaging tech we’re on our way to X ray.”
It took a few minutes for Dr. Newhouse to detach Ashley from the cardiac monitor as well as untie his arms from the armboards. With them sticking out laterally, it would have been impossible to get out through the door. When all was ready and Ashley’s hands were safely in his lap, Dr. Newhouse released the wheel lock with his foot. Then, with Dr. Newhouse pushing and Marjorie and Paul pulling, they rolled the OR table into the hallway. Except for the scrub nurse, who remained in the OR, everyone else trooped behind. Ashley stayed asleep and completely oblivious to the unfolding drama, despite his being in a sitting position and being jostled. With his head locked into the futuristic-appearing stereotaxic frame, he could have been a slumbering actor in a science-fiction movie.
Once in the corridor, everyone but Dr. Nawaz lent a hand pushing, although it was hardly necessary. The OR table rolled easily across the composite flooring, with only a quiet rumble from its considerable weight. When the group arrived in X ray, a discussion ensued whether to move Ashley from the OR table to the X-ray table. After weighing the pros and cons, it was decided it was best to leave him on the OR table.
Dr. Nawaz donned a heavy lead apron, as he insisted on personally aligning and supporting Ashley’s head while the films were taken. Everyone else retreated back out into the hallway. Ashley never awoke.
“I want the films developed before we move him back,” Dr. Nawaz told the technician, when she came in to retrieve the exposed plates. “I want to be absolutely certain they are adequate.”
“I’ll have them back in a jiffy,” the technician said brightly.
Dr. Newhouse returned inside the X-ray room to check Ashley’s vital signs. Paul and Spencer accompanied the X-ray technician to await the emergence of the X-ray film from the developer. Daniel and Stephanie found themselves momentarily alone.
“This is like a comedy of errors that’s not at all funny,” Stephanie whispered, with a disgusted shake of her head.
“That’s not fair,” Daniel whispered back. “The X-ray misunderstanding was nobody’s fault. I can see both sides, and it’s already water under the bridge. The X rays have been taken, so the implantation is back on track.”
“It doesn’t matter if it’s anyone’s fault or not,” Stephanie retorted with a pshaw. “It’s still a screw-up, and it’s been one thing after another from that fateful, rainy night in Washington until now. I keep asking myself what else can go wrong.”
“Let’s try to be a bit more optimistic,” Daniel snapped. “The end is in sight.”
Paul and Spencer emerged from the processing room with the technician a few steps behind. Paul clutched the X rays in his hands. “They look good to me,” he remarked, as he passed Daniel and Stephanie and went into the X-ray room. The others followed. Paul snapped the films up on the viewing box, switched on the light, and stepped to the side. The images were of Ashley’s skull surmounted by the opaque image of the stereotaxic frame.
Dr. Nawaz moved over, and with his nose close to the films, he carefully examined each in turn, orienting himself mostly by the indistinct shadows of fluid-filled ventricles in Ashley’s brain. For a moment, no one spoke. The only sound was Ashley’s deep breathing briefly obscured by the noise of Dr. Newhouse inflating the blood-pressure cuff on Ashley’s arm.
“Well?” Paul questioned.
Dr. Nawaz nodded reluctant approval. “They look okay. They should work.” He took out a marking pen, a protractor, and a precision metal ruler. With great care, he located a specific location on each film and marked it with a small X. “That is our target: the pars compacta of the substantia nigra on the right side of the midbrain. Now I have to figure out the x, y, and z coordinates.” He set to work drawing lines on the X rays and measuring angles.
“Are you going to do that here?” Paul asked.
“This is a good light box,” Dr. Nawaz said. He was preoccupied.
“We should get the patient back to the OR,” Dr. Newhouse said. “I’ll feel more comfortable with him reattached to the cardiac monitor.”
“Good idea,” Paul said. He immediately went to the foot of the OR table to lend a hand. Dr. Newhouse released the brake on the wh
eels.
Both Daniel and Stephanie peered over Dr. Nawaz’s shoulder and watched in rapt attention as he plotted the coordinates for the implantation needle, the guide of which would be firmly affixed to the frame.
With Paul pulling and Dr. Newhouse pushing, they maneuvered the OR table out of the X-ray room. Dr. Newhouse kept one hand on Ashley’s shoulder to help stabilize him as they moved. It probably wasn’t necessary, since Dr. Newhouse had taped Ashley’s chest to the cranked-up part of the OR table earlier, but he wanted to be certain.
Once in the hallway, Paul turned to face forward while holding on to the foot of the OR table behind his back. It was easier than trying to walk backward. He continued pulling, but his contribution was more for steering, since the OR table, with its four casters, had a tendency to yaw. Marjorie walked alongside, holding up the IV bottle but also ready to help support Ashley if need be. Spencer brought up the rear, giving occasional orders, which everyone ignored.
“His color is not great,” Dr. Newhouse complained in the bright fluorescent illumination of the hallway. “Let’s move it!”
Everyone upped the pace.
“His color was pasty from the moment he entered the front door,” Spencer said. “I don’t think it has changed.”
“I want him back on the monitor,” Dr. Newhouse said.
“We’re here!” Paul announced, as he thrust open the OR door and entered without turning around to face the OR table. In his haste, he failed to align the table with the doorway, causing the table to come in at an angle. The result was that one of the front corners thumped into the metal doorjamb with enough force to cause Ashley’s body to jolt against the tape that bound his chest to the table. The inertia of the stereotaxic frame caused a mild whiplash effect, snapping Ashley’s head forward obliquely. Both Dr. Newhouse and Marjorie reacted swiftly and caught Ashley’s arms, which had also flopped up from the impact.